The report below describes a patient undergoing surgery for a left heart catheterization. The entire procedure has been documented in detail, describing the step-by-step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.

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By: Sheila Haynes – Coding and Compliance Manager

Correct CPT and ICD-10 Codes:

93458 -26 Modifier = Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

R94.39 – Abnormal result of other cardiovascular function study

R07.9 – Chest pain, unspecified

I10 – Essential (primary) hypertension

PROCEDURE NOTE

DATE OF PROCEDURE: 05/04/21

PROCEDURE: Left heart catheterization with selective coronary angiography and ventriculogram.

INDICATIONS: 73-year-old woman with a history of hypertension who presents with acute chest pain and was found to have an abnormal stress test.

PROCEDURE IN DETAIL: After informed consent and appropriate sedation, the left radial artery was prepped in a sterile fashion and locally infiltrated with 2% Xylocaine. Using the Seldinger technique a 6-French sheath was inserted in the left radial artery without difficulty. Selective coronary angiography and ventriculogram was performed utilizing a 6-French Trak catheter, as well as a

6–French straight pigtail catheter. Coronary angiography was acquired during multiple views and a ventriculogram was performed utilizing the right anterior oblique view. After adequate imaging, the catheters and sheaths were removed, and adequate hemostasis was obtained with a TR band.

The patient tolerated the procedure well and left the Cardiac Cath Laboratory suite in stable condition.

FINDINGS:

Hemodynamics: Left ventricular pressure as well as aortic root
Pressure was normal with mildly elevated left ventricular end-
Diastolic filling pressure. No specific gradient was seen across the aortic valve suggesting aortic stenosis

Ventriculogram: In the right anterior oblique view ventriculogram was performed and demonstrated normal left ventricular systolic function of 60% with no segmental wall motion abnormalities. – No significant mitral- regurgitation was appreciated.

Coronary anatomy: The left main gave rise to the left anterior descending artery and left circumflex branch. The left main was free of any significant disease.

The left anterior descending artery was a good size vessel that wrapped around the apex and gave off several septal perforators, as well as three diagonal branches. Diagonal 2 was a larger vessel and the LAD as well as the diagonal branches had a small contour, and no high-grade obstructive lesions were appreciated.

The left circumflex is a large non dominant vessel which terminates within the AV groove and gives off a left posterolateral branch. The left circumflex gave off two obtuse marginal branch with the second obtuse marginal branch the larger vessel. The contour of this vessel and its branches were smooth, and no high-grade obstructive lesions were appreciated.

The right coronary artery was a large and dominant vessel which gave off an acute marginal branch and terminated as a right posterolateral and right posterolateral branch. The contour of this vessel was smooth and high-grade obstructive lesions were appreciated.

IMPRESSION: 

  1. Normal coronary arteries. 
  2. Preserved global left ventricular systolic function with no resting wall motion abnormalities. 
  3. Normal systemic pressures with mildly elevated left ventricular diastolic filling pressures. 

 

RECOMMENDATIONS: 

  1. Continue with aggressive lifestyle modification and medical therapy. 
  2. If the patient’s symptoms of chest pain and shortness of breath persist, consider work up for nonischemic and noncardiac etiologies.